Your Brain is Trying to Kill You

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[I am open to correction in any point of the post below].

….all diseases may, in some sense, be called affections of the nervous system, because in almost every disease the nerves are more or less hurt; and in consequence of this, various sensations, motions and changes, are produced in the body.

–Robert Whytt (1714-1766), Scottish Physician

 

One of my obsessions as a child (and as an adult) is probably related to my having Autism Spectrum Disorder, Level 1 (in my case, what used to be called “Asperger’s Syndrome). I have always been fascinated by the heart and death and why a particular medical condition caused the heart to stop beating, especially if the condition was not itself a heart disease. I’d wonder about how a gunshot that missed the heart could sometimes cause rapid (or in the case of certain head wounds, nearly immediate) cardiac arrest. I would see Daddy shoot a rabbit, and it would run for ten or twenty yards, then collapse, dead. Why did its heart beat strongly enough to support its running, then suddenly stop. Or, in another scenario, why can a human being hold her breath over three minutes (and for free divers, close to ten minutes), yet someone who slips underwater or chokes on a piece of meat suffers cardiac arrest, in some cases, in a minute or two. Recently I heard of a case of a twenty-eight year old man who choked on food, and when rescue arrived two minutes later, his heart had already stopped. He was revived and had no neurological effects—but what caused his heart to stop so quickly.

Now I am not a medical doctor; the furthest I got in the medical field was as an EMT-Basic who was not even certified to give IVs or advanced cardiac life support. However, I can read, and over the years I learned that people shot often bleed out and that people who drown in fresh water can suffer cardiac arrest within a couple of minutes from electrolyte imbalances, but what about the choking victim. In the case of the gunshot victim, why does the loss of 30-50% of blood volume arrest the heart? Surely that is enough blood to stretch the sarcomeres enough for systole to continue.

I used to blame the heart—it was strong, yes, but also very fragile—too fragile, and stops too easily or too quickly for doctors to halt the underlying cause of the arrest in time to avoid brain damage or death. It turns out that often the real culprit is not the heart, but the brain.

The brain responds to bodily trauma in a way that is often destructive to the body. True, there is the diving reflex that diverts blood flow to the heart and brain that allows some drowning victims to survive. However, the rapid release of neurotransmitters in trauma or asphyxia or even in a myocardial infarction (heart attack) can result in stoppage of the heart. In effect, the sympathetic nervous system which speeds up the body, with its neurotransmitters, conflicts with the parasympathetic nervous system, which slows the bodily functions, and this conflict can lead to cardiac instability and a fatal arrhythmia. While the electrical instability of the heart itself can cause a fatal ventricular arrhythmia during an MI, often the big straw that breaks the small camel’s back is a massive release of stress hormones that is “ordered” by the brain. In the case of severe bleeding, such as occurs in gunshot wounds, a nervous system mechanism causes the heart to slow down (“brady down”) and stop after 30-50% of blood volume is lost. Some head injuries, such as bullet wounds that affect key areas of the brain associated with the brain stem, cause, according to a military medic with whom I talked, almost immediate Torsades de Pointes (a chaotic heart rhythm) which progresses to ventricular fibrillation and death. The military uses pharmacological blockers to cut off sympathetic and parasympathetic signals to the heart, and sometimes that buys extra time to treat the patient. A recent animal study published by the National Academy of Sciences found that it is the release of neurotransmitters with conflicting effects on the body that leads to cardiac arrest, and when such parasympathetic and sympathetic signals are blocked, it buys several minutes in which the heart continues to beat until oxygen is totally exhausted. Yet this time could allow doctors to reverse the asphyxia without going through the (far more often than not) unsuccessful CPR and advanced cardiac life support in the face of cardiac arrest. Some scientists are not suggesting that in cases of asphyxia cardiac arrest, animal studies be done to determine whether pharmacological blocking agents to stop both parasympathetic and sympathetic signals from reaching the heart during asphyxia crises will keep the heart beating longer. Apparently there is a pattern to the course of dying in such cases, and knowing the pattern can help the timing of intervention. If blocking agents work in animals, this may be an option for human treatment.

Thus I should stop blaming the heart for early cardiac arrest in these conditions, at least in most cases, and blame the brain instead. A person with the strongest heart in the world could go into cardiac arrest quickly from asphyxia or blood loss if her nervous system effects cause the arrest.

As a philosopher of religion, this raises some issues for intelligent design arguments, at least those in the British natural theology tradition. Animal bodies are filled with examples of poor design; Francis Collins, who is a devout Christian, mentions some of them in his attack on intelligent design arguments (one of the design flaws is that instead of a totally separate, two-tube system for food and air, we have a system in which a flap closes the airway while we eat so that air goes into the trachea rather than the esophagus. Collins points out that any human engineer would have enough sense to avoid such a flawed design. The fact that our brains “try” to kill us during severe disease, trauma, or asphyxia does not suggest intelligent design—it suggests that some of the so-called protective mechanisms of the brain can make cardiac arrest occur more rapidly, resulting in less time for doctors to focus on underlying causes and resulting in the deaths of many people who would not otherwise die. Give me a good cosmological contingency argument any day over an intelligent design argument. Now I am not calling God incompetent; I believe it is possible that evolution became flawed due to an angelic fall (as we see in J. R. R. Tolkien’s mythical account, in which Melkor (or Morgoth) and his allies damaged nature itself in their rebellion against Eru (God).

I suppose the satisfaction of curiosity is a good feeling, but I am also frustrated with the slow progress of medicine in this area in which very few studies have been done. I am glad some scientists are working in this seminal area of science and medicine and hope that their efforts result in lives saved from an early death.

Your Tax Dollars Used to Take Organs

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Ambulance Interior

Imagine you have chest pains. Someone near you calls 911. At dispatch, two ambulances are sent for you. One has paramedics who will do their best to keep you alive, especially if you go into cardiac arrest; the medical workers in the other ambulance have a different purpose in mind–and that ambulance remains hidden. Before the ambulance arrives, your heart stops. A bystander begins CPR, and the ambulance arrives five minutes after that. Paramedics work on you for a half hour, then “call the code,” in effect, pronounce you dead. The paramedics working on you do not know about the other ambulance until their supervisor tells them to call the code. You are then transported to the other ambulance, and CPR is resumed. The other ambulance is marked, “Organ Preservation Unit.” CPR will be continued, not to save your  life, but to preserve your kidneys–and perhaps other organs–which will be removed after you arrive at the hospital. Those organs will be transplanted into others.

$1.5 million dollars of your federal taxpayer’s money is going to such a program in New York City. This practice is fraught with ethical problems. First, even if paramedics on a specific case do not know for sure whether the other ambulance is present, this program is public knowledge (there is a story in the December 1, 2010 New York Times about it). Any paramedic who receives a cardiac arrest or heart attack call will know that the other ambulance may be waiting. This could bring psychological pressure on the paramedics to stop CPR earlier than they would like. In addition, there are cases, especially early in the history of CPR, in which individuals with normal body temperature were successfully resuscitated after more than 30 minutes of CPR. It is clear that just because a patient has 30 minutes of CPR, this does not mean that the patient is dead; the brain can still be living and the heart resuscitatible. What would happen if the person’s heart restarted after the delay between stopping and resuming CPR? And even if the heart does not restart, the patient is only “dead” in a clinical, not a biological sense. It is removing the patient’s organs that kills the patient. This is medicine not to benefit the patient but to preserve organs, and it violates the fundamental end of medicine to “do no harm” (nonmaleficence). How much permission or informed consent can be given by families in such situations? Are the organ transplanters so desperate for organs that they will violate any principle of decency and medical ethics in order to obtain more organs? No utilitarian justification can make up for the distortion of moral medicine in this “trial” policy. It should be stopped immediately.

Ethics and Resuscitation

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CPR training

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Contemporary medicine brings with it ethical problems that human beings have not faced before. With the advent of modern resuscitative techniques, issues arise of when to start and stop cardiopulmonary resuscitation. In the 1950s, doctors in hospitals often carried a scalpel that was used when a patient went into cardiac arrest–the chest would be opened, and the heart massaged directly. This method saved the lives of many surgical patients as well as generally healthy pregnant women who had reactions to the anesthesia then routinely given during labor and delivery. It is still used today on trauma victims and on some heart attack victims. In 1960, William B. Kouwenhoven and his associates published an article in the Journal of the American Medical Association on closed-chest heart massage, which is still taught to the general public in CPR classes today. In the early days, doctors would sometimes work on a patient for over an hour, and some of these patients recovered without significant brain damage. Over the years, many other patients suffered severe, disabling brain damage. As CPR spread beyond drowning victims and victims of cardiac death due to a medical condition (such as a myocardial infarction, a “heart attack,” debates over when to use it intensified. CPR might, for example, bring back briefly a dying cancer patient, but what would be the point (unless the patient was waiting for a family member he wished to see before he died or another personal reason)? “Do-not-resuscitate” forms came into vogue, in which the patient or a proxy could let his wishes be known on whether he should be given CPR. I have had several relatives and friends die in peace because they did not go through CPR and advanced cardiac life support after cardiac arrest.

But what about the following scenario: a young woman collapses while jogging at a marathon. CPR is immediately started, along with advanced cardiac life support by the ambulance crew, and the patient is taken to a hospital. It is twenty minutes after her cardiac arrest. Doctors immediately pronounce her “dead on arrival.” This is an actual case; I am leaving out the names of the marathon, the city, and the hospital. What troubles me is that even today some doctors do not give up after twenty minutes, and patients do recover after an hour of CPR and ACLS. Some of these patients fully recover, physically and mentally. Why pronounce a young woman dead twenty minutes after cardiac arrest–maybe her heart only had an electrical glitch that, with treatment, could be controlled, or she could be given an implantable defibrillator and live for many years. We would not know–but twenty minutes seems so short in a decision that guarantees that the woman is dead.

One reason I feel strongly about death being pronounced so quickly in such a case is that my mother suffered a cardiac arrest. Doctors worked on her over two hours (and she did have some times in which her heart would beat off and on during that time), and eventually put one pacemaker line in that did not work; the second line did. She recovered without neurological effects and received a pacemaker and implantable defibrillator.

It seems that too many CPR decisions, both by paramedics and by hospitals, are more based on triage than on what could help patients (albeit a very small percentage of patients). I once asked a PA student who had worked at a hospital whether doctors would work on a trauma patient in cardiac arrest (which they sometimes do if the patient had signs of life at the scene). He replied it depended on how much time they had. I wonder if this is the same for patients in medical cardiac arrest. Now some of these patients may have had a DNR order that was discovered, so when the newspaper says someone was pronounced dead after a short ride to the hospital the DNR is the real reason. But when I read in the paper about drowning victims who were in the water less than five minutes being pronounced DOA twenty minutes later, this is troublesome. Would not there be a moral obligation, in a life or death situation, to try a bit longer, especially given the existence of some successes in the past? If a fifty-year-old man has his first MI, a witnessed arrest with bystander CPR, is twenty minutes’ effort enough for him? I am sure doctors mean well and are looking at “evidence-based medicine,” and studies that say the success rate of ACLS after 20 minutes is extremely low. Because of such studies, paramedics are calling codes over after 20 minutes of CPR and ACLS in the field. In an unwitnessed arrest, this may be justified. If the arrest is witnessed with no CPR given before the ambulance arrived, it may be justified. I am not so sure if the arrest is witnessed.

In the case of trauma, I know of at least two instances, one in Tennessee, the other in North Carolina, in which paramedics said that a patient was dead–and the patient was not. I can understand triage at a trauma scene; the chance of CPR and resuscitative thoracotomy (opening the chest and massaging the heart directly, which is done with some trauma victims) have such a low chance of success with trauma victims) is almost nil (although, contra most articles, there have been survivors of blunt traumatic arrest who fully recovered–check out Woodbury, Minnesota). So if the number of paramedics is limited and someone else with a pulse and severe injuries needs to be treated, in those cases it is acceptable to consider the person in cardiac arrest dead. Otherwise, outside of severe head injuries with brain matter, obviously broken necks, obvious severe bodily trauma, and clear signs that too much time has passed, why not try CPR? Sometimes trauma victims swallow their tongues or get debris in their mouths, and they arrest due to asphyxiation. What is wrong with clearing the airway, trying CPR for a few minutes, seeing if there is any rhythm on the monitor. If not, what harm does it do? It doesn’t harm the patient. And a life might be saved.

I realize that physicians will say, “You’re not a physician and have no right to say anything about these issues.” No, I am not a physician; I volunteered as an EMT-Basic for eight months, but the knowledge from the training is extremely small compared to a physician’s. But I can read articles in medical journals, I can use a dictionary, and I can interpret the data and cases I read. I do know that there is a difference between someone with a shockable rhythm and someone whose initial rhythm is PEA or asystole, and that death will be pronounced more quickly in the latter situations unless a readily reversible cause of the arrest can be found. But the clincher for me is that my mother would have died if the doctors had given up on her. Thank God for them, and for my brother, who pushed the doctors to continue CPR even after they had considered giving up. It is too bad that other patients do not have such an advocate.